Losing a significant amount of weight, whether through bariatric surgery, diet, or exercise, is a remarkable achievement. However, many individuals find themselves facing a new challenge: excess, loose skin that can diminish the positive impact of their weight loss. Body contouring plastic surgery offers a solution by removing this excess skin and refining the body's shape, further enhancing the results of weight loss efforts.
Understanding Body Contouring
Body contouring encompasses a range of plastic surgery procedures designed to address excess fat and skin. These procedures are not exclusive to post-weight loss patients; they can also benefit individuals with localized fat deposits or age-related skin laxity. For those who have experienced massive weight loss (MWL), body contouring can be a crucial step in completing their transformation.
The Importance of Weight Stability
Before considering body contouring, it's essential to achieve weight stability. Weight fluctuations, whether gains or losses, can negatively impact the aesthetic outcomes of these procedures. Ideally, patients should maintain a stable weight for a minimum of 12 months before undergoing body contouring.
Common Body Contouring Procedures
Massive weight loss patients often require multiple surgical procedures to address excess skin and fat throughout their entire body. Several different procedures for removing excess skin are available, and most people need a combination of surgeries to get the look they seek. A doctor can help determine which procedures will benefit each patient the most. The procedures include:
- Panniculectomy: This procedure removes the apron of excess skin and fat (pannus) that hangs below the belly button. Typically, panniculectomy or lower body lift procedures are performed as the first stage.
- Lower Body Lift: This addresses excess skin and fat from the stomach, buttocks, and outer thighs.
- Tummy Tuck (Abdominoplasty): A tummy tuck removes excess skin and tightens weak or separated abdominal muscles. In a panniculectomy, the patient is placed in a supine position, and the lower abdominal pannus is removed without any undermining or separation of the skin and fat from the abdominal wall. The lower incision is placed inside the mons pubis area, and the upper incision is placed below the umbilicus. This procedure does not address the upper abdomen or flanks or the rectus diastasis. The umbilicus is left in place or sometimes "floated" where it is undermined or released from the abdominal wall and re-positioned lower than its anatomic position. At least two drains are used and left in place for one to two weeks. An abdominoplasty, on the other hand, addresses the entire abdomen. With the patient in the supine position, the lower abdominal tissue is removed. The lower incision is usually placed inside the mons pubis area in order to lift the ptotic mons, and the upper incision extends above the umbilicus, depending on the degree of tissue laxity. After circumscribing the skin around the umbilicus to preserve the belly button, the entire abdomen is then undermined up to the level of the costal margin and xiphoid. The rectus muscles are plicated with sutures, and the skin is then closed in layers. A new umbilical site is marked and created with a knife, and the umbilicus is brought out to the skin and sutured in place. One to two drains are used and kept in place for one to two weeks.
- Arm Lift (Brachioplasty): An arm lift removes excess skin that hangs down from the upper arm. Skin excision for brachioplasty is done on either the posterior or medial brachium with the patient in the supine position and arms flexed at 90 degrees. The skin excess is determined by pinching and placing marks on the arms. Excess fat is accounted for at this point, and secondary marks can be made. The skin is removed segmentally to account for discrepancies from the existing marks. Over-aggressive removal of tissue may result in widened or hypertrophic scars which can be uncomfortable and unsightly to patients. Scars that cross the axilla and extend onto the chest wall may incorporate a z-plasty to prevent hypertrophic scarring.
- Thigh Lift: This procedure gives the inner thighs a sleeker appearance. The thighs are arguably the most difficult area to treat in MWL patients. Many women retain adiposity in their thighs despite weight loss. Excess skin in the lateral thigh may be addressed through lower body lifting or belt lipectomy as previously described. Liposuction may be needed to contour the lateral thighs or debulk the thighs in cases of severe lipodystrophy. Multiple techniques have been described to treat the thighs, and some involve fascial anchoring to prevent labial spreading and scar migration. However, the medial thigh skin excess must be addressed whether it is proximally located near the groin or diffusely down the entire thigh. Essentially, a wedge of skin and fat is removed full thickness from the medial thigh. The concept is similar to a brachioplasty. The incision extends proximally in the groin or gluteal crease and distally to the knee as needed to remove dog ears and produce a satisfactory contour. The procedure is done with the patient in lithotomy position, and drains are incorporated. In the author’s opinion, this procedure carries a higher risk for dehiscence, lymphedema, and infection than other body contouring procedures.
- Breast Lift (Mastopexy): A breast lift firms up breasts by tightening tissue and removing excess skin. Losing large amounts of weight can sometimes cause the breasts to take on a sagging or drooping appearance. In a mastopexy procedure, the nipple areolar complex (NAC) diameter is reduced and transposed to a more anatomic position on the breast. Some patients opt to increase their breast volume by having an implant or by the use of autologous fat which has been suctioned from another area. Techniques of auto-augmentation with derma-glandular flaps, that would normally be resected during mastopexy, have been described with mixed results. An augmentation-mastopexy may be done in one or two stages depending on the size of the implant desired, surgeon experience, patient co-morbidities, and expectations. A small implant may be used in one stage whereas if a larger implant is needed, two stages are preferred since less skin can be removed in order to contour the breast. Moreover, combining mastopexy with augmentation reduces the vascularity of the tissue flap containing the NAC and may lead to delayed healing, implant infection and loss of the NAC. Furthermore, the position of the implant is difficult to control and asymmetries may result as there are several variables being addressed simultaneously. For most patients, two-stage mastopexy-augmentation surgeries are safer and reduce the need for revisions later. Men with MWL may have deflation of their chest with resultant excess skin and benefit from rejuvenation of the breast. As opposed to a woman, a mastopexy would produce a shaped, projecting breast and be feminizing for a man. Therefore, the goals for a male would be skin removal in a cosmetically sensitive fashion so as not to be embarrassing when in public. This is usually accomplished through an inverted T- scar with transposition of the NAC or an inframammary crease scar with free nipple grafting. The latter procedure involves removal of the NAC then skin grafting the NAC back into an appropriate position on the chest.
- Facelift (Rhytidectomy): A facelift gives the face a smoother, younger appearance and gets rid of excess skin around the neck. The face and neck are the least commonly treated areas for MWL patients. This is due to the severity of skin laxity present in other areas including the abdomen. Face and neck procedures are similar to non-MWL patients with two exceptions: the amount of deflation present from the loss of adipose tissue in the face is often more significant and the eyebrow tends to be more ptotic. The goal of facial rejuvenation in these patients is to remove excess skin and restore structures to their anatomic position and augment the volume of the subcutaneous tissue.
Liposuction as an Adjunct
Liposuction can be incorporated into body contouring procedures to remove stubborn fat deposits. It is not a weight loss surgery but can help refine the contours of treated areas. Liposuction is the manual removal of fat cells using small cannulas. The procedure involves making small stab incisions and introducing lidocaine and/or epinephrine through small cannulas into the area to be treated. The infiltrated epinephrine decreases the blood loss resulting from the procedure while the lidocaine decreases the amount of the general anesthetic needed. Patients with low BMI generally require skin excision alone whereas those with BMI >30 may benefit from liposuction in combination with skin excision procedures to remove or debulk some areas. Areas that may be treated with liposuction include the neck, arms, thighs, flanks and back.
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The Surgical Process
Excess skin removal often takes place in stages, requiring multiple surgeries. Certain procedures, like a lower body lift or a panniculectomy combined with a tummy tuck, can be performed during the same surgical appointment. Depending on the procedures, surgery may occur in a hospital with an overnight stay or at a surgical facility as an outpatient procedure.
Pre-operative Preparation
Prior to surgery, patients may need to:
- Undergo blood work (lab tests).
- Stop taking certain medications that increase bleeding risk, such as aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs).
- Refrain from taking vitamins and herbal supplements.
- Quit smoking or using tobacco products.
Important Considerations
- Excess skin removal surgeries can only take place after bariatric (weight loss) surgery.
- It may take one to two years to achieve the goal weight after bariatric surgery.
- Patients need to maintain weight loss for at least six months before getting body contouring procedures.
- Bariatric surgeons perform weight loss procedures, while plastic surgeons perform body contour procedures.
Candidacy for Plastic Surgery After Weight Loss
Individuals with significant weight loss resulting in hanging, excess skin folds, and stubborn fat pockets are often ideal candidates. Non-smokers or those willing to quit are also preferred. Drooping skin folds and areas exhibiting excess fat and skin that has lost elasticity can frequently follow significant weight loss, having an effect on self-confidence and also increasing the risk of skin infections and hygiene conditions.
Timing of Plastic Surgery After Weight Loss
It's generally recommended to wait at least 12 to 18 months before undergoing plastic surgery after weight loss procedures. Timing varies based on individual healing rates, weight loss results, lifestyle habits, and other factors. Following all post-weight loss surgery recovery instructions, committing to a healthy and nutrient-rich diet, staying physically active, monitoring mental well-being, avoiding tobacco products, and having realistic expectations of surgical outcomes are all ways that can help further progress toward being ready to schedule cosmetic procedures.
Scarring and Recovery
As with all surgical procedures, some scarring is inevitable. However, experienced plastic surgeons strategically place incisions in natural folds or areas that can be easily concealed to minimize visibility. Recovery depends on the extent of the procedures performed. Major surgery may require several weeks of home recovery to ensure the best possible healing process.
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Benefits of Plastic Surgery After Weight Loss
Plastic surgery after weight loss can take individuals another step toward reaching their ultimate goals. Losing large amounts of weight is a very big accomplishment, and it can be very disappointing to see that once the extra weight is gone, it is replaced with loose, excess skin. Plastic surgery after weight loss addresses this issue with the aim of giving patients the results they were hoping for before they lost weight. Plastic surgery has evolved to treat these unique issues faced by this patient population and has demonstrated beneficial effects.
The Rise of Bariatric Plastic Surgery
Bariatric surgery rates have increased in the United States concurrent with the rise in obesity. As a result of the massive weight loss from these surgeries, patients are left with a different set of functional and cosmetic issues related to excess skin. According to the American Society for Metabolic and Bariatric Surgery (ASMBS), the number of bariatric surgeries increased to 179,000 in 2013. Similarly, bariatric plastic surgery procedures including tummy tuck, thighs, breasts, and arm lifts grew at their fastest rate in four years in recent years. In 2014, nearly 45,000 patients opted to have plastic surgery to correct changes resulting from weight loss surgery. According to the American Society of Plastic Surgeons (ASPS), thighs and upper arms lifts had their biggest single-year increase (9%) in five years in 2014. Body contouring after MWL surgery is a growing field in constant evolution. Conventional procedures are not always able to address these patients needs.
Risks of Bariatric Plastic Surgery
Risks of bariatric plastic surgery are related to the number of procedures done, operative time, surgeon experience, and co-morbidities. They generally include hematoma, infection, seromas, wound dehiscence, skin necrosis, deep venous thrombosis (DVT), pulmonary emboli (PE), and death.
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